Proventil

Sarah E. Hampl, MD

• Assistant Professor of Pediatrics
• Children? Mercy Hospitals & Clinics
• University of Missouri?Kansas City School
• of Medicine
• Kansas City, Missouri

The brace can be removed for showering and sleeping after the first week unless otherwise directed by your physician asthmatic bronchitis pregnancy trusted 100mcg proventil. You are allowed to run asthmatic bronchitis humidifier 100 mcg proventil visa, golf asthma treatment in qatar discount proventil 100 mcg on line, and do other non-pivoting sports at 5 months depending on how your knee is progressing and any other associated injuries asthma treatment team generic proventil 100mcg line. Full return to contact sports is allowed at 6 months depending on conditioning of your knee asthma treatment without inhaler cost of proventil. A brace is usually not required however some patients prefer the added security of the brace for a period of time as they get back to sports asthmatic bronchitis icd-9 code order cheap proventil on-line. For injection of corticosteroids and other intra-articular therapies Equipment Required For Joint Injections! Discuss steroid flare- occurs 2-5% of injections and lasts 2-3 days the Knee Region! Treatment is to address knee disorder via systemic treatment, injection or surgery Anserine Bursa! All patients were prospectively evaluated before intervention and at 1, 3, and 6 months after the treatment. Only minor adverse events after injection were noted, and symptoms resolved within 48 hours after the injection. Keywords: platelet-rich plasma, knee osteoarthritis, treatment safety, intra-articular injection this is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4. The number of patients with osteoarthritis continues to increase as the world population ages. Common movements used in daily life in Japan include foor-sitting, squatting, and kneeling (e. Pharmacologic therapies include the use of paracetamol, non-steroidal anti-infammatory drugs, and opioids. Using an aseptic technique, approximately 36 mL of venous blood were drawn from the antecubital vein in an effort to avoid irritation and trauma to the platelets. Blood pressure, heart rate, and body temperature were measured before and at 30 minutes after the injection. After the injection, the patients were instructed to refrain from physical exercise for at least 24 hours, but no restriction was specifed regarding activities of daily living. The interval between injections, as well as the number of injections, was determined based on previous studies. Measurement of growth factor concentrations A single freeze-thaw cycle was used to induce platelet activation and the release of growth factors. The samples were thawed and centrifuged for 10 minutes at 10,000 rpm, and the supernatants were tested. All evaluations were conducted in multi-well plates, and all measurements were performed in duplicate. The color intensity of each well was measured using a spectrophotometer (Varioskan; Thermo Fisher Scientifc, Yokohama, Japan) at 450 nm and a wavelength correction of 570 nm. The onset, duration, and severity of events such as knee pain, stiffness, swelling, and burning sensation near the injection site were recorded in detail. Radiographs were obtained at baseline (before injection) and at the 1-month, 3-month, and 6-month follow-up visit. Radiographs in the supine anteroposterior view, lateral view, and skyline view were obtained during the same visits. The demographic and clinical characteristics of the patients are shown in Table 1. Osteoarthritis affected the right knee in 6 patients and the left knee in 4 patients. Physical examination did not reveal hydrarthrosis of the knee in any patient, and no patient underwent synovial fuid aspiration. Blood and growth factor fndings the fndings of the hematological analysis and growth factor concentrations are presented in Table 2. Twenty-two adverse events were reported in relationship to 30 injections in 10 patients. Radiographic fndings showed that there was no progression in the K-L grade from baseline to 6 months after the end of the treatment. Table 3 Adverse events in 10 patients with knee osteoarthritis who received intra-articular injections with platelet-rich plasma Patient Injection Adverse event Duration 1 1st Acute local pain, stiffness Immediately 2nd None 3rd None 2 1st Uncomfortable feeling Immediately 2nd Subcutaneous bleeding 48 h 3rd None 3 1st Cold chill, pain during walking, itching in the knee 48 h 2nd Expanding acute pain at injection site 48 h 3rd Pain during walking, itching in the knee 48 h 4 1st Tingling sensation in the knee Immediately 2nd None 3rd Pain during walking, itching in the knee 24 h 5 1st None 2nd None 3rd None 6 1st Pain during walking 24 h 2nd Pain during walking 24 h 3rd Acute knee pain, stiffness 24 h 7 1st Tingling sensation in the knee 24 h 2nd Stiffness Immediately 3rd Acute pain in the area behind the knee joint 1 h 8 1st Itching in the knee Immediately 2nd Pain during walking, itching in the knee 24 h 3rd None 9 1st Pain during walking, itching in the knee 1 h 2nd Sharp acute pain in the knee 1 h 3rd Feeling of pressure in the knee Immediately 10 1st Acute pain in the knee 48 h 2nd Acute pain in the knee 48 h 3rd Stiffness 48 h 46 Yu Taniguchi et al. Ten patients with knee osteoarthritis received intra-articular injections with platelet-rich plasma, administered once per week for three weeks. The patients with knee osteoarthritis received intra- articular injections with platelet-rich plasma, administered once per week for three weeks. All adverse events observed were minor and included acute knee pain, stiffness, tingling sensation, and walking pain just after the injection. These adverse events were observed for 22 of the 30 injections administered (73%), but all symptoms resolved spontane- ously within 48 hours. The pathogenesis of knee osteoarthritis is complex and driven by infammatory mediators within the affected joint. The use of alternative biomarkers should be considered in subsequent clinical comparative trials. First, this was an open-label study, so no comparison with a control group was performed. Second, the follow-up period was relatively short as a clinical trial to verify the effcacy. This future study will be a multi-center, double-blind, controlled clinical trial; the control group will receive hyaluronic acid injection. This therapy has the potential to induce pain relief that is maintained for up to 6 months, but further study is needed to verify the effcacy. Prevalence of knee osteoarthritis, lumbar spondylosis, and osteoporosis in Japanese men and women: the research on osteoarthritis/osteoporosis against disability study. Hip, knee, and ankle kinematics of high range of motion activities of daily living. Activities of daily living in non-Western cultures: range of motion requirements for hip and knee joint implants. The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition. Comparison between hyaluronic acid and platelet-rich plasma, intra-articular infltration in the treatment of gonarthrosis. Platelet-rich plasma vs hyaluronic acid to treat knee degenerative pathology: study design and preliminary results of a randomized controlled trial. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Inverted V-shaped high tibial osteotomy compared with closing-wedge high tibial osteotomy for osteoarthritis of the knee. Validity and reliability of the Japanese Orthopaedic Association score for osteoarthritic knees. A ten- to 15-year follow-up observation of high tibial osteotomy in medial compartment osteoarthrosis. Serum hyaluronan levels and radiographic knee and hip osteoarthritis in African Americans and Caucasians in the Johnston County Osteoarthritis Project. Reference intervals of serum hyaluronic acid corresponding to the radiographic severity of knee osteoarthritis in women. Effcacy of intra-articular platelet-rich plasma injections in knee osteoarthritis: a systematic review. Mechanism of race-dependent platelet activation through the protease-activated receptor-4 and Gq signaling axis. Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. Platelet-rich plasma stimulates porcine articular chondrocyte proliferation and matrix biosynthesis. Biochemical investigation of the effects of human platelet releasates on human articular chondrocytes. Platelet-released growth factors enhance the secretion of hyaluronic acid and induce hepatocyte growth factor production by synovial fbroblasts from arthritic patients. Does intra-articular platelet-rich plasma injection provide clinically superior outcomes compared with other therapies in the treatment of knee osteoarthritis For my generation, Europe was an aspiration of peace, prosperity and unity that we brought to life through our single currency, free movement and enlargement. Of living in a society where you can be who you are, live where you like, love who you want and aim as high as you want. The people of Europe made their voice and their aspirations heard in record numbers at this years European Parliament elections. They presented Europes institutions and leaders with a clear task to be bold and to be decisive. To match this aspiration with action, we must rediscover our unity and inner strength. My Commission will listen to the people of Europe and be bold where it makes sense for us to act, leaving national, regional and local actors to deliver where they are best placed to do so. Changes in climate, technology and demography are transforming our societies and way of life. In the next five years, we have to work together to allay fears and create opportunities. But it can only do so by bringing people together and upgrading our unique social market economy to fit todays new ambitions. As we embark on this journey, we must make the most of all of our strengths, talent and potential. We must focus on equality and creating chances for all, whether for women or men, whether from East, West, South or North, whether young or old. And we must give ourselves the resources we need to achieve our ambitions, notably through our next long-term budget which should be agreed as swiftly as possible. We should not be shy about being proud of where we are or ambitious about where we want to go. As we move forward together, I want a more inclusive and open approach to the way we work. I want to strengthen the Commissions partnership with the European Parliament, the voice of citizens. In this spirit, I have consulted far and wide and have inspired myself from my discussions with the political groups in the European Parliament, as well as from the European Councils Strategic Agenda for 2019-2024. They are not an exhaustive work programme but rather aim to frame our common work. Within each chapter you will find the policies I intend to use to help us deliver on our goals. The Political Guidelines focus on six headline ambitions for Europe over the next five years and well beyond: A European Green Deal An economy that works for people A Europe fit for the digital age Protecting our European way of life A stronger Europe in the world A new push for European democracy We will adapt and update as challenges and opportunities inevitably emerge, but we will always stick to the principles and the aspirations outlined in these guidelines. A European Green Deal I want Europe to strive for more by being We currently have a goal of 40% emissions the first climate-neutral continent. I will propose to extend the Emissions I have been inspired by the passion, conviction Trading System to cover the maritime sector and energy of the millions of our young people and reduce the free allowances allocated to making their voice heard on our streets and in airlines over time. Becoming the worlds first climate-neutral To complement this work, and to ensure our continent is the greatest challenge and companies can compete on a level playing opportunity of our times. It involves taking field, I will introduce a Carbon Border Tax to decisive action now. This should be fully innovation and research, redesign our compliant with World Trade Organization economy and update our industrial policy. I will also To help us achieve our ambition, I will review the Energy Taxation Directive. A just transition this will include the first European Climate To help drive the change we need, I will put Law to enshrine the 2050 climate- forward my plan for a future-ready neutrality target into law. We will be a world leader in circular I have been inspired by the passion, economy and clean technologies. We will conviction and energy of the millions of work to decarbonise energy-intensive our young people making their voice industries. It is our generational duty to deliver for Europe is an industrial economy, and for many them. But we good for our planet must be good for our need to go further and faster if we are serious people, our regions and our economy. Cohesion Funds play a crucial role in supporting our regions and rural areas from 5 Political Guidelines | Ursula von der Leyen, Candidate for the European Commission President East to West, from South to North to keep up But public finances alone will not be enough. To achieve this, I intend to put forward a strategy for green financing and a In this transition, we must recognise and Sustainable Europe Investment Plan. We all share the same ambition but As part of this, I will also propose to turn some may need more tailored support than parts of the European Investment Bank others to get there. I believe that what is good for our planet the bank is already the largest multilateral must be good for our people, our regions provider of climate finance worldwide, with and our economy. We will ensure a just 25% of its total financing dedicated to climate transition for all. The Sustainable Europe Investment Plan We will support the people and regions most will support 1 trillion of investment over affected through a new Just Transition Fund. We have to be more ambitious when it comes To this end, I will propose a European to our 2030 targets.

Are there safety risks asthma definition 2-dimensional shapes generic proventil 100 mcg mastercard, such as losing control while driving your power chair or car Tethered spinal cord is a condition where scar tissue forms and holds the spinal cord itself to the dura asthma flare up definition order proventil toronto, the soft tissue membrane that surrounds it asthma treatment jamaica cheap 100 mcg proventil visa. This scarring prevents the normal flow of spinal fluid around the spinal cord and impedes the normal motion of the spinal cord within the membrane asthma definition 2-dimensional shapes buy cheap proventil 100mcg. Tethering causes cyst formation; it can occur without evidence of syringomyelia asthma symptoms 1 generic 100 mcg proventil amex, but post-traumatic cystic formation does not occur without some degree of cord tethering asthma bracelet cheap proventil uk. Untethering involves a delicate surgery to release the scar tissue around the spinal cord to restore spinal fluid flow and the motion of the spinal cord. If a cyst is present, a shunt may be placed inside the cavity to drain fluid from the cyst. Surgery usually leads to improved strength and reduced pain; it does not always bring back lost sensory function. Syringomyelia also occurs in people who have a congenital abnormality of the brain called a Chiari malformation. During development of the fetus, the lower part of the cerebellum protrudes from the base of the head into the cervical portion of the spinal canal. Symptoms usually include vomiting, muscle weak- ness in the head and face, difficulty swallowing, and varying degrees of mental impairment. Adults and adoles- cents with Chiari malformation who previously showed no symptoms may show signs of progressive impairment, such as involuntary, rapid, downward eye movements. Other symptoms may include dizziness, headache, double vision, deafness, an impaired ability to coordinate movement, and episodes of acute pain in and around the eyes. Syringomyelia can also be associated with spina bifida, spinal cord tumors, arachnoiditis, and idiopathic (cause unknown) syringomyelia. Signs of the disorder tend to develop slowly, although sudden onset may occur with coughing or straining. Surgery results in stabilization or modest improvement in symptoms for most people although delay in treatment may result in irreversible spinal cord injury. Recurrence of syringomyelia after surgery may make additional operations necessary; these operations may not be completely successful over the long term. Up to one half of those treated for syringomyelia have symptoms return within five years. While everyone deals with loss and change in their own way, there are aspects of the adjustment process that many people share. At first, many react to paralysis as if nothing really happened, refusing to accept that changes in their body and in their ability to move are not going to get better or heal in ways they always have. Some may see the injury as an annoyance similar to getting the flu that will pass with time. These can be seen as defense mechanisms that allow a person time to mobilize other defenses. Guilt may be part of the mix, too, especially in people whose poor judgment or self-destruc- tive behavior may have contributed to their disability. They may see themselves as victims whose lives are ruined because they can never live the happy life they always knew they would; they see no way out. The best advice, easier said than done, is to let anger run its course, and let it go. These thoughts are common for individuals who are newly paralyzed; many persons continue to hold on to them, even the irrational ones, long after their injury. Its important not to confuse the blues we all experience when something bad happens with depression. Depression is a medical condition that can lead to inactivity, difficulty concentrating, a signifi- cant change in appetite or sleep time, and feelings of dejection, hopelessness or worthlessness. Suicide is greater for people with spinal cord injuries compared to the nondis- abled population. To be sure, paralysis ignites many emotions and feelings, most of them nega- tive. A persons reactions to all this baggage may result in behavior that is bad for health and happiness. For example, a person who feels worthless may not take proper care of his or her bladder or skin or nutrition. Also, people with a history of alcohol and/or substance abuse may return to old patterns of self- destruction. Generally, at some point following paralysis, people may begin to admit that they have a serious condition, though they may hold on to the belief that the situation is not a long-term problem. As the process continues, it is important for people to contact others who share similar experiences. There are peer support groups for every sort of condition related to paralysis in most communities, including the Reeve Foundation Peer and Family Support Program. The Internet is a great tool for connecting with paralysis survivors who have been down the same path and can testify that there is still a future ahead full of life and rewarding experience. Given time, a person will eventually come to terms with their loss and reach the final stage of the grieving process: acceptance. Most people come to accept a realistic view of their condition, find meaning in life, and begin to make plans for the life ahead of them. Early on, people may be motivated to work hard at therapy to gain strength and function, still believing, perhaps, that paralysis can be beaten by sheer will power. While treat- ments for paralysis are coming, the best approach is to move forward and live a full life now. Hope for restoring function is fine and not unrealistic, but if it means waiting on the sidelines until medical research delivers the cure, its an aspect of denial. People who set these kinds of goals report greater life satisfaction, and they feel less shameful about their condition. Most people have the same personality, the same sense of style and humor as they did before being paralyzed; there is no reason not to strive for the same things. It may be necessary to ask others for help, even when doing everything on your own becomes a stubborn way to assert your independence. Adjustment to paralysis is a process; changing ones thoughts, feelings, and behavior doesnt happen overnight. Life will always deliver your share of frustration, pain, loss, and the unpredictable actions of others. You cant change that; but you can change the way you let such events afect you, especially if anger is an issue. Simple relaxation techniques, such as deep breathing and pleasing imagery, can help calm down angry feelings. It takes time to rebuild ones identity, to find a new balance in relationships, to discover that what is important is what is happening now. Dont ignore the support and problem-solving experiences of others in similar circumstances. In 1979 he survived a nasty automobile accident which left him paralyzed from the chest down. Tapping into his reserves of compassion, he has armed himself to ride out the storms. But we all have a certain narra- tive in our head how to fix this, how it will happen. Live the life you have instead of waiting for the life you want or longing for the life you had. One of the most comforting ways to deal with the confusion and to begin to see a full and active life ahead is to connect with someone who has already been where you have been, had the same questions and is now thriving in life. Peer mentors empower people impacted by paralysis to live as independently as possible, engage with their communities, and navigate life transitions. There are some things that are so important and personal that they cant be understood except by another person who has gone through them. Craig met his wife after he was injured and subsequently had three little boys; he was able to ofer great insights and advice on being a husband and a dad while living with a spinal cord injury. As we continued to meet, Craig was very helpful in suggesting what kind of goals I should set for my rehab. I did exceptionally well, and I give a lot of the credit for my success to the support and guidance I received from Craig at the time. Once I was discharged and went home, I sought out Craig for advice on how to adjust to my new life in the wheelchair away from the rehabilitation center. Craig gave me a lot of encouragement and shared specifcs of how he lives his daily life. Craig helped me determine what kind of vehicle my family should buy in terms of what would work best for me at that moment and would also be easily adapted for me to drive in the near future. In addition to the relationship that I had with Craig, his wife really helped my wife to understand what to expect and how to handle certain situations. Throughout our relationship, the most important thing Craig taught me is that I am still the same man, father and husband that I was before my injury and to not let the injury change that about myself. If you are living with paralysis, or you are the parent, spouse, or family member of an individual living with paralysis, you might benefit from someone who has experienced what you are experiencing. The Reeve Foundation peer mentors are adept at sharing their personal knowledge in order to help you. Although these approaches to well- ness and healing fall outside of mainstream traditions, they may offer a bridge between eastern and western medicine. Dont think of these alternatives as an either/or substitute for your regular care but rather as a compliment. His book, Alternative Medicine and Spinal Cord Injury: Beyond the Banks of the Mainstream, details numerous treatments that you wont hear about in most rehab centers. But according to John- ston, only 10-20 percent of what physicians practice has been scientifically proven. Ayurveda: Indias ancient holistic medicine attempts to keep one healthy and disease free. Certain spices are recommended for clearing toxins after any sort of injury, including turmeric, black pepper, ginger, coriander, fennel, and licorice. Alas, people with paralysis can now expect many of the same health problems as their nondisabled contemporaries. Higher rates of diabetes and obesity, lower levels of physical activity, and changes in body composition add to the risk. Fresh extract of skullcap (of the mint family) may reduce nerve inflammation; a tincture of milky oats. Aromatherapy: Essential oils are used to prevent respiratory infections, promote mucus clearing, fight depression, and promote sleep. Magnets: There are claims they enhance circulation, promote wound healing, and reduce carpal tunnel syndrome. Edgar Cayce: Americas most famous medical intuitive believed the main cause of multiple sclerosis was the lack of gold; his therapy involved administering gold vibrational energy through two electrotherapy devices, the wet cell battery and radial appliance. Mindfulness meditation is not hard, there is no right or wrong way to do it, but it may take practice to quiet the mind for an extended period of time. Most people meditate with closed eyes, but you can focus on an object, a candle, for example.

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They are also helpful in evaluating symptoms of hypotension particularly if they are intermittent and infrequent [11 asthma definition spirometry proventil 100 mcg low cost,12] asthma definition 600d 100mcg proventil overnight delivery. Many machines are now available for the purpose that are convenient asthma treatment new zealand buy proventil 100 mcg on-line, inexpensive and relatively accurate asthma over the counter 100 mcg proventil amex. Home readings are on average 12/7 mmHg less than office measurements asthma definition xi purchase 100 mcg proventil, even in normotensive subjects asthma symptoms 5 month old discount proventil 100 mcg mastercard. However, many factors that contribute to blood pressure variability including circadian variation, food and alcohol ingestion, exercise and stress are more difficult to control in the home environment. Technique and precautions When giving instruction about self-measurement of blood pressure at home, the following points should be made [10]. Office values of 140/90 mmHg correspond to 24-hour average values of approximately 125/80 mmHg. Clinical decisions may be based on day, night, or 24- hour mean values, but 24-hour values are preferable. The following situations are ones in which a better knowledge of what is happening to a patients blood pressure over 24 hours can lead to different therapeutic decisions [10]. Evaluation of newly diagnosed hypertensive patients without target organ damage In these patients, therapeutic decisions will depend mainly on how blood pressure is evaluated. Isolated office hypertension the condition refers to persistently elevated office blood pressure readings (140/90 mmHg at several visits) while 24-hour ambulatory blood pressure values are normal (<120/80 mmHg. Diagnosis can also be based on home blood pressure mean values <135/85 mmHg, after several days recording. Isolated office hypertension is encountered in about 10% of the general population and accounts for a non-negligible population of individuals in whom hypertension is diagnosed. Several, but not all, studies have reported this condition to be associated with target organ damage and metabolic abnormalities, which suggests that it may not be an entirely innocent phenomenon. Lifestyle changes and a close follow-up should be implemented in all patients with isolated office hypertension. Drug treatment is instituted when there is evidence of target organ damage or high cardiovascular risk profile. This refers to individuals with normal office blood pressure (<140/90 mmHg) but elevated ambulatory blood pressure values (isolated ambulatory hypertension. These individuals display a greater than normal prevalence of target organ damage. Refractory hypertension this may be the result of a genuinely resistant hypertension, non-compliance or an exaggerated white-coat hypertension. The best clue to this exaggerated white-coat effect is a persistently elevated office pressure in the absence of target organ damage. A clue to this may be 22 Clinical guidelines for the management of hypertension that although the average blood pressure level and heart rate fall during the night, their variability increases. Intermittent symptoms possibly related to blood pressure Episodes of light-headedness, particularly in patients who are on antihypertensive medication, may be a manifestation of transient hypotension. Episodic hypertension Episodic symptoms accompanied by transient elevation in blood pressure may occur in a variety of conditions, including phaeochromocytoma and panic attacks. There are huge swings of blood pressure during the day depending to a large extent on changes of posture and physical activity, and relatively stable but high pressure at night when the patient is supine. Autonomic neuropathy is common in type 1 diabetes and has been attributed to interruption of both vagal and sympathetic control of the circulation. The former is manifested by a relatively fixed heart rate and the latter by orthostatic hypotension. In common with patients with idiopathic orthostatic hypotension, blood pressure remains high at night. Most normotensive patients and perhaps 80% of hypertensives have at least 10% drop in blood pressure during sleep compared with daytime average. There is about a 3-fold increased risk of cardiovascular events among those with non-dipping blood pressure or pulse patterns. Technique and precautions [13] When measuring 24-hour blood pressure, care should be taken to follow certain procedures. There is evidence that subjects in whom nocturnal hypotension is blunted and thus exhibit a relatively high night-time blood pressure may have an unfavourable prognosis. The blood pressure thresholds for definition of hypertension with office, 24-hour ambulatory and home measurements are given in Table 4. However, whether or not an excessive rise in blood pressure during exercise adds diagnostic precision to blood pressure at rest depends on the response of the cardiac output: if the exercise-induced rise in cardiac output is impaired in hypertensives, exercise blood pressure no longer has independent prognostic power [14]. On the whole, systolic blood pressure measurement during exercise, though potentially valuable, is not recommended as a routine procedure in hypertensives [5]. Pseudo-hypertension [4] this term refers to the rare situation where blood pressure measurements by the usual indirect sphygmomanometry are much higher than direct intravascular measurements. These differences are usually attributed to very stiff and calcified arteries that are 24 Clinical guidelines for the management of hypertension nearly impossible to compress with the bladder in the usual blood pressure cuff. The Osler manoeuvre (palpating the walls of the brachial artery when blood flow has been interrupted by inflating the cuff higher than systolic pressure) has been recommended as a simple, but neither sensitive nor specific, measure to diagnose the condition. More precise methods involve intra-arterial measurements and perhaps an infusion of an intravenous antihypertensive agent to calibrate the difference between direct and indirect blood pressure measurements. The benefit of lowering blood pressure in older patients with stiff arteries is well established. Evaluation of hypertensive patients Background During the initial office evaluation of a hypertensive patient a comprehensive history should be obtained. Careful physical examination with focus on signs suggesting secondary hypertension and target organ damage is done and routine laboratory tests are recommended. Clinical history A clinical history for hypertension should include the following assessments [5]. Physical examination In addition to methodological blood pressure measurement (see above), physical examination should search for the following signs of hypertension [3]. Laboratory investigation Laboratory investigations should be directed at providing evidence of additional risk factors, searching for secondary hypertension and assessing presence or absence of target organ damage. They include routine tests, recommended tests (based on recent studies) and specific tests for extended evaluation of hypertensive complications and causes of secondary hypertension [3,5]. Signs of target organ damage Hypertensive cardiac damage Atrial (S4) gallop is a common and vital clue to the presence of hypertensive heart disease. Severe diastolic dysfunction may result in flash pulmonary oedema, despite a normal ejection fraction. Classification into concentric or eccentric hypertrophy and concentric remodelling by using the wall to radius ratio (values >0. Hypertensive vascular damage Hypertensive vascular damage can be identified by changes in the optic fundi. These are important in the assessment of both the severity and duration of elevated blood pressure. The clinical Keith-Wagener-Barker classification (1939) describes the combined effects of hypertension and arteriosclerosis on the retinal vessels [18]. Extensive or generalized arteriolar narrowing resulting in changes in arteriovenous crossing (arterial nicking. In hypertensive patients presenting early in the course of the disease, haemorrhages, exudates and papilloedema are rarely observed. Grade 1 and 2 arteriolar changes are often noted, but no evidence is available that these can be used as evidence of target organ damage or have a significant prognostic value. Ultrasound examination of the carotid arteries with measurement of the intima- media thickness and detection of plaques has been shown to predict the occurrence of both stroke and myocardial infarction. The relationship between carotid artery intima- media thickness and cardiovascular events is continuous but a threshold 0. Hypertensive vascular damage can also be identified by measuring large artery compliance [20,21]. The increasing interest in systolic blood pressure and pulse pressure as predictors of cardiovascular events, stimulated by evidence of the beneficial effects of lowering blood pressure in the elderly and in isolated systolic hypertension, has Evaluation of hypertensive patients 29 encouraged the development of techniques for determining large artery compliance. Two of these techniques have been well developed: namely the pulse wave velocity measurement and the augmentation index measurement device (SphygmoCor. Both are of interest, particularly in view of the claim that aortic blood pressure (and therefore the pressure exerted on the heart and brain) may be different from that which is usually measured at the arm and may be a better predictor of outcomes. Endothelial dysfunction or damage is an early marker of cardiovascular damage [22,23]. Current studies on circulating markers of endothelial damage may soon provide simpler tests of endothelial dysfunction. Such markers include nitric oxide and its metabolites, endothelines, cytokines and adhesion molecules. Hypertensive renal damage Hypertensive renal damage can be identified by certain laboratory tests. Blood urea nitrogen, serum creatinine, serum electrolytes and urinalysis (particularly for proteinuria) are the only measures of renal function that are currently routinely recommended for evaluation of all hypertensive patients. However, these are very insensitive indicators of the onset and progression of hypertensive nephrosclerosis. The presence of mild renal insufficiency has been defined as serum creatinine values 1. A slight increase in serum creatinine and urate may sometimes occur when antihypertensive therapy is instituted or intensified but this should not be taken as a sign of progressive renal deterioration. Hyperuricaemia, defined as serum urate levels >7 mg/dL, is frequently seen in untreated hypertensives and has also been shown to correlate with the existence of nephrosclerosis [25]. Blood pressure control with all agents (except dihydropyridine calcium channel blockers and central or peripheral sympathetic blockers) reduces albuminuria. The amount of microalbuminuria is proportional to the severity of systolic, diastolic and mean blood pressure elevation. Moreover, microalbuminuria predicts the development of ischaemic cardiovascular events related to the development of atherosclerosis. It is an indicator of increased vascular permeability and hence altered barrier function of the endothelium. When albumin leaks into the interstitial space, cellular injury occurs due to free radicals and cytokine production, which is enhanced by the presence of albumin. Subjects with microalbuminuria and type 2 diabetes mellitus have an approximate total mortality of 8% and a cardiovascular mortality of 4%, annually. These values are up to 30 Clinical guidelines for the management of hypertension four times higher than those of patients without microalbuminuria. Similar increases in cardiovascular mortality are also present in people with microalbuminuria and without diabetes [26]. Routine assessment of microalbuminuria in diabetic patients is well advised, but in hypertensives without diabetes mellitus its value is still debatable. This may allow more precise evaluation of the patients prognosis at the initial visit [27]. Hypertensive brain damage Hypertensive brain damage is suggested by the following features [28]. Secondary hypertension [3,4] Evaluation There are several clinical and laboratory features that will suggest a diagnosis of secondary hypertension on initial evaluation for elevated blood pressure. If suggestive clues for identifiable cause of secondary hypertension are found, additional investigation should be performed. The diagnostic methods listed in Table 5 as initial are usually adequate screening procedures. If they are abnormal, the listed additional procedures should be performed along with whatever other tests are needed to confirm the diagnosis. It can be acute or chronic, unilateral or bilateral, and does not have to be associated with renal insufficiency. The most common renal parenchymal disorders associated with hypertension are chronic glomerulonephritis, polycystic kidney disease and hypertensive nephrosclerosis. Investigation Assessing the presence of protein, erythrocytes and leucocytes in the urine as well as measuring serum creatinine concentration are the appropriate functional screening tests. If these tests are positive, a detailed investigation for kidney disease should follow. Renal parenchymal disease may be excluded if urinalysis and serum creatinine concentration are repeatedly normal. Renal ultrasound has now almost completely replaced intravenous urography in the anatomical exploration of the kidney. It provides all the necessary anatomical data about kidney size and shape, cortical thickness, urinary tract obstruction and renal masses. Renovascular disease [4,31,32] Renovascular disease is the second most common cause of secondary hypertension. Two clinical subgroups comprise the majority of patients with renovascular hypertension. Atherosclerotic disease, making up nearly 70% of total renovascular hypertension, usually involves the proximal third of the renal artery. Left untreated, most lesions progress leading to complete occlusion and renal failure.

A-29 Response: Additional epidemiological studies of leukemia and lymphoma risk in workers exposed to dichloromethane were identified and added to Appendix D (Section D asthma symptoms 7 order cheap proventil on-line. Please comment on whether this determination is scientifically supported and clearly described asthma treatment pregnancy order proventil visa. Please comment on data available for dichloromethane that may support an alternative mode of action asthma no inhaler purchase proventil in india. Comments: Five reviewers agreed that a mutagenic mode of carcinogenic action is supported asthmatic bronchitis uk order proventil once a day. One reviewer asthma definition 86d buy discount proventil on-line, whose area of expertise focuses on genotoxicity asthma uncontrolled symptoms order proventil 100 mcg on line, commended the presentation of the series of tables of genotoxicity data and also suggested that a table(s) be added that would summarize, for a particular rodent species, target tissue, and exposure route, data outlining key events in the mode-of-action timeline to support analysis of temporality and dose-response concordance with respect to genotoxic and nongenotoxic modes of action. This reviewer observed that the in vitro data are probably sufficient to conclude that dichloromethane is an in vitro mutagen, but there are no in vivo data in rodents to address whether dichloromethane can induce mutations either in target or nontarget tissues, and concluded that the data are therefore insufficient to prove that dichloromethane acts via a mutagenic mode of carcinogenic action. The same reviewer indicated that there is no evidence to strongly conclude that dichloromethane acts via a nonmutagenic mode of action and that one must therefore conclude that the mode of action for tumor induction is unknown. This reviewer suggested that discussion of these points within the mode of action section would result in a more balanced presentation of the positive and negative findings, specifically with respect to the relevance of the mode of action to humans. To address the suggestions pertaining to additional tabular presentation of the data, four new tables were added to Section 4. Three of these new tables (Tables 4-35 to 4-37) present summaries of the relevant genotoxicity data by type of assay, species, and target organ, and the fourth new table (Table 4-38) presents a summary of the data discussing the strength of the evidence, the target-tissue specificity, dose- response concordance, and temporality. This weight-of-evidence analysis includes explicit acknowledgement of the lack of in vivo demonstration of mutations in critical target genes for carcinogenesis (see Section 4. Please comment on whether the selection of this study for quantitation is scientifically supported and clearly described. Comments: Four reviewers supported the use of the 2-year drinking water study in mice (Serota et al. One reviewer considered the discussion pertaining to this choice to be clear, but that it was not within the reviewers primary area of expertise. One reviewer also suggested that the analysis of combined datasets from oral and inhalation routes, or analysis based on the arithmetic mean of slope factors for the two exposure routes, should also be considered. The rationale for selection of the oral slope factor based on the oral exposure study over the value derived by route-to-route extrapolation was clarified in Section 5. Please comment on whether this approach is scientifically supported and clearly described. Two reviewers disagreed with the use of linear extrapolation, indicating that this approach ignores repair systems and other biological processes that would make a threshold model more appropriate. Response: Consideration of repair systems and other biological processes that occur at low doses would require a biologically-based (toxicodynamic) model that accounts for the biological processes involved in a response. However, sufficient data to develop a biologically-based toxicodynamic model for dichloromethane are not available. Therefore, consistent with 2005 Cancer Guidelines and in the absence of data to support a toxicodynamic model, linear extrapolation was retained. To determine a cancer slope factor, one must select a point or percentile from within that overall distribution at which the cancer risk is to be assessed. In assessments without probabilistic models, one is effectively attempting to determine the overall average population cancer risk, assuming no additional knowledge to inform differentiation of risk among the population. This average population risk would correspond to th the mean internal dose, or 50 percentile, of the model-predicted distribution for the population as a whole. Because there is information about subpopulation sensitivity for dichloromethane that is not typically available, the choice was made to estimate risk for the average. This reviewer suggested that this issue be addressed in the discussion of uncertainties. Please identify and provide the rationale for any other studies that should be considered. One reviewer reiterated the recommendation that additional discussion of issues regarding interspecies extrapolation at sites other than liver and lung be addressed in the discussion of uncertainties. One reviewer did not comment on this question because it was outside this reviewers area of expertise. Responses to the previous issues raised by two reviewers are addressed under Carcinogenicity Charge Question 1. Use of high-exposure conditions in animal experiments is a standard and accepted practice in conducting toxicology studies. For example, the mean body weight of high-dose males was comparable to the controls until week 90 of the study, and mean body weight of high-dose female mice was 09% lower than the control. One reviewer disagreed with the use of the linear extrapolation (as also noted in response to Carcinogenicity Charge Question C4. Response: A response pertaining to the use of the linear extrapolation is provided under Carcinogenicity Charge Question C4. One reviewer repeated the recommendation offered in response to other charge questions that the uncertainties section should provide additional discussion of issues regarding interspecies extrapolation at sites other than liver and lung. Comment: One reviewer did not support the use of the sensitive population (as had also been expressed in response to Carcinogenicity Charge Question C4. Cancer risks, however, have historically been estimated based on an average population risk. As discussed in response to comments under Carcinogenicity Charge Question C4, in the case of dichloromethane, average cancer risk was estimated for a sensitive group based on genotype, a group that is estimated to represent approximately one-third of the entire population. Focus on this portion of the population, which would be considered a higher risk population, is warranted based on current understanding of genetic variation, metabolism, and mode of action. Comments: One reviewer did not think the use of a risk estimation based on the combined risk of lung and liver tumors was justified. Two reviewers raised concerns regarding the assumption of normality of the underlying risk distributions of the liver and lung tumors. If these assumptions were not met, the 95% confidence limit calculated for the combined lung and liver tumors risk is approximate. The other reviewer noted the potential for the lack of normality in the probability distributions to result in an underestimation of the resulting 95% upper confidence level on the summed risk. This reviewer provided a reference (Salmon and Roth, 2010) that discusses this issue in more detail. Response: In situations in which tumors at multiple sites are seen in an animal bioassay, a unit risk estimate based on tumor incidence at only one of these sites will result in an underestimation of the total carcinogenic potency. Specifically, the combined risk was generated from the first order models for male mice. Where the separate tumor incidences to be added together all fit this description, the procedure used by U. Response: Use of the age group categorized as <18 years was chosen because this represents the age range during which growth occurs. Figure B-11 (upper panel) shows that liver size decreases with age up to 17 years, based on data. Lacking data on changes in the fraction of blood flow to the liver with age, the distribution function used to describe that fraction has no dependence on age of the individual. Comments: One reviewer also raised the question of the reversibility of the neurological effects seen with dichloromethane, as well as other solvents, noting the relatively short recovery periods observed post-exposure in animal studies. Although limited by small sample A-37 size and low statistical power of the study, the findings of Lash et al. The commenter also supported the use of the human neurotoxicological data from Cherry et al. Although the three epidemiological studies examining serologic measures of liver function (Soden, 1993; Kolodner et al. The potential RfC derived based on these are slightly higher than the RfC derived 3 from rat hepatic lesions (0. The basis for selection of the oral slope factor based on the oral exposure study over the value derived by route-to-route extrapolation was clarified in Section 5. The distribution of ages over which the workers were exposed was estimated from the demographic details provided by Lash et al. The corresponding distribution of oral exposures for the population as a whole was then estimated, using the model distributions for the full U. The primary uncertainty in this analysis is that it is based on effects seen an average of 5 years post-exposure, and so does not capture what is likely to be stronger effects seen at the time of exposure. The latter two uncertainties stem from lack of knowledge of the mechanism for the neurological effect. This analysis demonstrates that the RfD based on rat liver lesions should also be protective of potential neurological effects. Given the uncertainty in the level of exposure and degree of response evaluated by Lash et al. The commenter stated that the allowance for inter-human toxicokinetic variability double counts and misconstrues the nature of the dose-response curve. In particular, the commenter stated if one assumes a tolerance distribution-based dose-response curve for quantal endpoints, an experimental animal dose corresponding to a low (e. The commenter stated that the method employed in the assessment seems to implicitly assume that all of the variability in dose-response among rats is attributable to toxicodynamics and that all of the variation in A-40 response at a given dose in humans is attributable to toxicokinetics. The commenter concluded that the net result is to yield an RfC that is overcorrected for human inter-individual variation to a degree that is not possible to know with the available analyses. Response: the method employed assumes neither that all of the variability in dose-response among rats is due to toxicodynamics, nor that all of the variation among humans is due to toxicokinetics. The comment that the RfC overcorrects for human interindividual variation assumes that the commenter knows that the variation is less than the correction actually used. The commenters conclusion that the RfC is overcorrected is therefore unsupported by any data. The categories that were evaluated were: genotoxicity, reproductive toxicity, developmental toxicity, immunotoxicity, neurotoxicity, epidemiological, and human dosimetry studies. A recent study by Selgrade and Gilmour (2010) used a similar method to Aranyi et al. In order to incorporate known variability in human physiology and metabolism of dichloromethane into internal dosimetry, Monte Carlo analysis of the human model was performed to derive probability distributions of internal dose, as reported in David et al. The shape of the resulting dose distribution can be used to quantify the variability and uncertainty in internal dose with respect to variability in human physiology and variability and uncertainty in dichloromethane metabolism. The human model was run repeatedly using a random sample of each parameter from its respective parameter distribution in each iteration. Internal doses predicted for all iterations collectively defined a distribution for internal dose. Repeated Monte Carlo analyses (at 10,000 iterations each) th yielded 99 percentile values of internal dose in the liver or lung that differed by <2%. Physiological parameter and partition coefficient values were initially taken from the literature as described in David et al. B-1 Hence, the distributions for physiological parameters and partition coefficients were not updated in the Bayesian analysis of David et al. Blood:air partition measured by using human samples; other partition coefficients based on estimates from tissue measures in rats. Therefore, supplemental data sources were chosen to define a number of the physiological parameter distributions in a way that should fully characterize the variability in the human population for individuals between 6 months and 80 years of age. Since many physiological parameters vary with age and gender, a structured approach will be used where an individuals age and then gender may be selected from the overall population distribution for these characteristics (the male:female ratio in the population declines with age, for example. Dosimetry simulations can then be run for each such individual to obtain an overall population distribution of internal doses. For estimating cancer risk where risk is due to the cumulative exposure over months or years, however, the ideal approach would be to simulate the time-course of internal doses in a given individual tracked over a lifetime or significant portion thereof. Further, we know, for example, that some individuals who are lean in their youth may become obese by middle-age, while others (through lifestyle-changes) change in the opposite direction; and these changes may be reversed by the time the individual reaches 70 or 80 years of age. First the population-mean value of VmaxC, VmaxC,mean, was sampled from the range of uncertainty represented by a log-normal distribution 0. Given those genotype frequencies, the interindividual variability was then characterized by rescaling the activity distributions from Warholm et al. Therefore, the data from the 14- to 18-year-old individuals were assumed to represent adult values, and hence, an evaluation of the change versus adult could be made by normalizing to these data. The data in Figure B-2 are compared to two model predictions: the allometric-based 0. Therefore, this fitted coefficient will be used when estimating the total activity for individuals <18 years of age. To test the revised allometric function versus the data, these values were then plotted against individual age, and a linear regression was performed, as shown in Figure B-3. While the slight trend in the regression indicates that not all of the age-dependence may be captured by 2 this function, the low R and small value of the slope indicate that the observation is not B-8 statistically significant and that further attempts to explicitly account for age dependence would lead to minimal improvement. This representation of the data also clearly shows that the overall variability in the scaled activity (VmaxC) is fairly constant across ages: approximately sixfold, ranging from ~0. However, given the database for this analysis from adults and children, the resulting distribution is expected to provide a good prediction of variability in the overall population. Because first-order constants are multiplied by tissue volumes in calculating total metabolism rates, and 1 -0.

Self-concept of children with cerebral palsy compared with that of children without impairment asthmatic bronchitis contagious person to person purchase proventil 100 mcg line. Beyond the divide between cognition and discourse: using interpretative phenomenological analysis in health psychology asthma symptoms for infants buy proventil 100 mcg overnight delivery. Health related quality of life of children and adolescents with cerebral palsy: hearing the voices of children asthma treatment nz proventil 100 mcg for sale. Parent and professional reports of the quality of life of children with cerebral palsy and 92 associated intellectual impairment asthma symptoms on skin cheap 100 mcg proventil visa. Parenting and childhood anxiety: theory asthmatic bronchitis exacerbation proventil 100 mcg cheap, empirical findings and future directions asthma educator trusted 100 mcg proventil. This experience was chosen because it allowed me to realise something important about myself, in that I think I have a fear of getting things wrong, moreover the experience made me reflect on this fear and reframe it through an analogy. In addition, designing and delivering this information sharing session allowed me to realise the importance of disseminating psychological knowledge, the impact of which is considered in the context of both the National Occupational Standards for Psychology (2002) and Delivering for Mental Health, (2006. Reflection Employing Gibbs (1988) model, I reflect on the experience of being asked to design and deliver psychological knowledge for dissemination. Progressing through the stages of the model, I consider the impact of my thoughts and feelings before considering what I could do differently in the future. Reflective Review Writing this reflective account has allowed me to realise that I am always learning about myself. Moreover, reflecting on the experience, and on reading about reflection has allowed me to further appreciate the benefits and need for reflection. It is an activity that I have grown to enjoy, and one which I intend to embrace as much as 95 possible as my career develops. I also consider whether given the level of insight and learning achieved through reflection, it could be proposed that we have an ethical need to engage in self-reflection for the benefit of our practice and our clients. Involvement in the group experience allowed me to reflect on my relationship with different theories and to learn something about myself and my practice; it also allowed me to see progress as I attempted to change my practice following such realisation. Reflection Employing Kolbs (1984) model of experiential learning, I reflect on the experience of not knowing what was expected of me, and my experiences in the group. Moving through the model, I recognise a tendency I have to want to diffuse states of high emotional arousal. Working with the impact of my thoughts, feelings, and new learning, I attempt to deal with my difficult feelings when having to sit with and tolerate high arousal. Moving on from the group experience itself, I reflect on the evidence base, and I consider service management and delivery and the benefits of group therapy for individuals with personality disorder. I frame this in the context of National Occupational Standards for Psychology (2002. Reflective Review Through reflection I came to appreciate my tendency to want to diffuse situations and the need to change this for the sake of my practice. In addition, I came to appreciate how much I learned through the group experience and the benefits this would have for individuals with personality disorder. I was also able to reconcile my relationships 98 with different therapeutic models. I conclude by reflecting on how personal growth can aid practice as it allows a deeper appreciation of the clients experience. It focuses on issues related to the health and health care of neonates, children, young people and their families, including areas such as illness, disability, complex needs, well-being, quality of life and mental health care in a diverse range of settings. The reviewer may at their own discretion opt to reveal their name to the author in their review but our standard policy practice is for both identities to remain concealed. All manuscripts are reviewed as rapidly as possible, and an editorial decision is generally reached within 4-6 weeks of submission Decisions on manuscripts will be taken as rapidly as possible. All manuscripts are reviewed initially by the Editors and only those papers that meet the scientific and editorial standards of the journal, and fit within the aims and scope of the journal, will be sent for outside review. If you have reviewed or authored for the journal in the past year it is likely that you will have had an account created. For further guidance on submitting your manuscript online please visit ScholarOne Online Help. If you would like to discuss your paper prior to submission, please contact the editorial office at bcarter@uclan. Other conventions In order to protect the identity of children, families and staff, authors should use pseudonyms and remove any information leading to identification of any of the individuals described in the study. The only time that the Editors will consider overriding this convention is if children, families and staff have specifically consented for their identity not to be protected in this way (evidence of this will be required. All contributors who do not meet the criteria for authorship should be listed in an `Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, writing assistance, or a department chair who provided only general support. Ensure that any tables, figures or images are submitted in separate files, and are clearly labelled. Manuscripts should not exceed 3500 words unless specifically approved by the Editor. These details should be presented separately to the main text of the article to facilitate anonymous peer review. Figures supplied in colour will appear in colour online regardless of whether or not these illustrations are reproduced in colour in the printed version. In some instances, the Editor may suggest that lengthy materials submitted as text may be better suited to be hosted online only. Visit English Language Editing Services on our Journal Author Gateway for further information. For further information please visit Offprints and Reprints on our Journal Author Gateway. We additionally provide the corresponding author with a complimentary copy of the print issue in which the article appears up to a maximum of 5 copies for onward supply by the corresponding author to co-authors. It allows final revision articles (completed articles in queue for assignment to an upcoming issue) to be hosted online prior to their inclusion in a final print and online journal issue which significantly reduces the lead time between submission and publication. Study Comparison group 2 Comparison with published norms 1 No comparison (not included in review) 0 2. Research Questions clear, aims stated 2 Question/Aims Questions or aims unclear 1 Questions and aims unclear or not stated 0 Section score / 4 3. Measurement of Level of Motor Function assessed disability Yes, reported and discussed 2 Yes reported 1 No 0 Assessed using a standardised measure 1 Non-standard measure/not measured 0 Section score / 3 6. Data on non- Data supplied regarding non participants respondents Yes, discussion of demographics 2 Yes, acknowledged not discussed 1 No 0 Section score / 2 7. Inclusion/exclusion Inclusion/Exclusion criteria stated Yes 1 No 0 Section score / 1 8. Confounding Factors Any potentially confounding factors (for example, study includes proxy report without highlighting that the data is not all self-report) 10. Discussion Conclusions flow from results Yes 1 No 0 Recommendations are made for clinical practice or future research based upon the findings of the study Yes 1 No 0 109 Limitations Acknowledged Yes 1 No 0 Section score / 3 Total Score / 36 110 Appendix 1. The Journal of Child Health Care publishes original theoretical, empirical and review papers which have application to a wide variety of disciplines. Peer review policy Journal of Child Health Care operates a strictly blinded peer review process in which the reviewers name is withheld from the author and, the authors name from the reviewer. In general, Editors will seek advice from two or more expert reviewers about the scientific content and presentation of submitted articles. Article types the Journal of Child Health Care publishes original theoretical, empirical and review papers on child health issues. How to submit your manuscript Before submitting your manuscript, please ensure you carefully read and adhere to all the guidelines and instructions to authors provided below. Please read the Manuscript Submission guidelines below, and then simply visit mc. In this case copyright in the work will be assigned from the author to the society. We seek to protect the rights of our authors and we always investigate claims of plagiarism or misuse of articles published in the Journal. 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We attach high importance to our quality service levels in copy-editing, typesetting, printing, and online publication online. We also seek to uphold excellent author relations throughout the publication process. We value your feedback to ensure we continue to improve our author service levels. It allows final revision articles (completed articles in queue for assignment to an upcoming issue) to be hosted online prior to their inclusion in a final print and online journal issue which 119 significantly reduces the lead time between submission and publication. Further information Any correspondence, queries or additional requests for information on the Manuscript Submission process should be sent to the Editorial Office at bcarter@uclan. As your healthcare professional I would like to inform you of some new research that is being carried out, as I thought that you may be interested in taking part. The research is investigating what it is like to be a child who has cerebral palsy. It is hoped that the results of the study will provide us with further insight into the experience of living with cerebral palsy from the childs point of view. Taking part would essentially involve your child meeting with the researcher for approximately an hour, during which the researcher will talk to your child about cerebral palsy and the things they do in their life, for example, hobbies, school, friends etc. If you think that you would like to take part then please read the enclosed information forms for further details. If you wish to take part, then you can contact Donna Redford (Trainee Clinical Psychologist) directly on 07981475203 / 01294 323072. If you would like to take part, then you and I would meet together for about an hour, at a clinic near to where you live. When we meet, we will make a poster together and I will ask you about yourself and cerebral palsy. When we are talking I might record what we are saying, just so that I dont forget what we have said. Everything you say will be kept secret and no-one will know what you have said because I will take your name and date of birth away from what you say in the meeting. The only reason I would have to tell someone what we have said is if you tell me something that makes me think that you or someone else might be in danger. If this happens then I would have to tell someone just to make sure that you are safe. If you decide that you dont want to take part even after we have started then that is ok. We can stop at any time for a break and you can leave with your parent when you decide you want to leave. If you would like to take part then you can phone me on 01294 323072 / 07981475203 or you can return the enclosed slip in the free post envelope or tell the person who gave you this information sheet. We are asking if you would join in a research project to find the answer to the question what is it like to be a child that has cerebral palsy So please think about this and talk about it with your family, friends, teacher or doctor if you want to . We are doing this research so we can find out more about what it is like to be a child who has cerebral palsy. I dont know much about cerebral palsy, but since you have it, I think you must be a bit of an expert. I would like you to tell me about how you feel about having it, and how it affects your life. You have been invited to take part because you have cerebral palsy and know what it is like to be a child with cerebral palsy. We are hoping that eight people with cerebral palsy will be involved in our research. I will ask your parent to complete a questionnaire that asks about different things like your mood and what you 125 are good at. After this, we will make a poster and we will talk about cerebral palsy, I might ask you some questions about how you feel and what you find difficult about having cerebral palsy. When we are doing the interview, if you agree, then I will record it so that I dont forget what we have been talking about. Anything you tell me will be kept private and no one else will know about what you have said, apart from my supervisors, who are also involved in doing the research. Anything you say can be used in my research but no-one will be able to tell that it was you that said it because everything will be anonymised, which means that your name or personal details will all be removed. The only thing that would mean I have to speak to someone else is if you tell me something that makes me think that you or someone else is in danger. If this happened then I would have to tell the appropriate people, but I would tell you about that first, this would be done to make sure that you are safe. Also, if you decide at any time that you dont want to carry on with the interview, then that is ok and we will stop. All we will do is make a poster and talk about how you feel about having cerebral palsy.

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References

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